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Health Insurance Name
Health Insurance ID
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Business and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Business may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Business employees, volunteers, and program participants and their families.
Patient/Parent/Guardian Signature